Updated Pediatric and Adult Obesity Algorithm

Veronica Hackethal, MD

How will the updated pediatric and adult obesity algorithm impact both your patients and practice? Scroll through this slideshow to find out. 

The Obesity Medicine Association (OMA) recently released the 2018 updates to The Obesity Algorithm® (originally published in 2013) for pediatric and adult patients. The algorithm provides detailed information on pathophysiology, evaluation, and management of obesity and obesity-related complications. What has been updated? And how will these updates impact your patients? Scroll through the slideshow above to find out. 

2018 Pediatric, Adult Obesity Algorithm.1 The algorithm is updated annually and the major updates this year focus on training, board review, epidemiology, the obesity paradox, interpretation of DXA results, NEAT, anti-obesity drug updates, functional foods, supplements, and OTC medications, and investigational anti-obesity medications. 

Obesity, Adiposopathy, Obesity Paradox. Between 2015 and 2016, the prevalence of obesity was estimated to be 40% in US adults, 18.5% in youths, and higher among non-Hispanic black and Hispanic adults. Adiposopathy, or sick fat disease, is when increased fat tissue leads to anatomic changes and endocrine, immune, and metabolic dysfunction. The obesity paradox is the idea that increased fat tissue may be protective in certain cases (eg, cardiovascular disease events, stroke, acute respiratory distress, and chronic kidney disease). 

Obesity Classification. Obesity was classified for BMI, percentage of body fat, and waist circumference. The 5 different categories for BMI (in kg/m2) are normal (18.5-24.9), overweight (25-29.9), class I obesity (30-34.9), class II obesity (35-39.9), and class III obesity (≥40). Overweight/obese is classified as ≥32% body fat for females and ≥25% body fat for males. Overweight/obese is classified as ≥35” waist circumference for females and ≥40” for men.

Edmonton Obesity Staging:

  • Stage 0: No risk factors, physical symptoms, functional limitations, or impaired well-being
  • Stage 1: Subclinical risk factors for obesity-related chronic disease and mild physical symptoms, psychopathology, functional limitations, and impaired well-being
  • Stage 2: Obesity-related chronic disease and moderate psychopathology, functional limitations, and impaired well-being
  • Stage 3: End-organ damage, significant psychopathology, significant functional limitations, and impaired well-being
  • Stage 4: Severe obesity-related chronic disease and disability, disabling psychopathology, functional limitations, and impaired well-being

Evaluation. A comprehensive evaluation of the patient with overweight/obesity should include history, a physical examination, laboratory tests, and diagnostic testing. 

Body Composition: DXA Interpretation. DXA measures fat mass and lean soft tissue mass or soft tissue mass and bone mineral mass. Lean mass and fat composition is highly variable due to genetics, gender, race, age, nutrition, and physical activity. A normal lean body mass is 75% of total body mass and normal fat mass is 25% of total body mass, but can go up to >70%. 

Energy Expenditure. The widest variance in energy expenditure among individuals is in non-exercise activity thermogenesis, or NEAT, and can range between 150-500 kcal/day. Maximizing steps taken per day is recommended to maintain/improve health; the OMA recommends that individuals walk 10 minutes for every hour seated and that patients be encouraged to monitor daily steps with a pedometer. While <5000 steps a day is average for the US adult, 10 000 steps per day is considered active.

 

Individualized Treatment. Individualized treatment plans include dieting, activity, and counseling. Dieting plans can consist of calorie/carb restriction, food journaling, and very low-calorie diet programs. Also, setting an activity goal, such as moderate intensity exercise 150 minutes a week can be effective in weight management. Counseling can help eliminate provider bias/stigma and help patients identify self-sabotage while developing a strong support system. 

Anti-obesity Medications. Currently there are 9 FDA-approved anti-obesity drugs available for appropriate patients. Investigational anti-obesity drugs include SGLT 1 and 2 inhibitors, oxyntomodulin analogues, lorcaserin/phentermine, and canagliflozin/phentermine.

Please note: A recent, post-marketing trial showed no difference in major cardiovascular events between lorcaserin and placebo over 3.3 years (first weight loss drug to show cardiovascular safety).2

Functional Foods, Supplements, OTC Medications. Functional foods suggested by the OMA include dietary fiber, prebiotics, probiotics, caffeine, green tea, green coffee extract, phytoestrogens, and conjugated linoleic acid. So-called weight loss supplements that have been banned by the FDA include DMAA , ephedra (ma huang), bitter orange/synephrine, DNP, and phenylpropanolamine. The only OTC anti-obesity therapy that is FDA-approved is orlistat. 

A note from the American Board of Obesity Medicine. "Obesity medicine specialists, certified by the American Board of Obesity Medicine, dedicate a portion or all of their practice to the treatment of obesity. They perform a medical evaluation (history, physical, laboratory, body composition) and provide medical supervision for lifestyle change (nutrition, activity, behavior change), medications, or very low-calorie diets. Obesity is a chronic medical disease and often requires lifelong treatment."

References: 

1. Bays HE, Seger, J, Primack C, et al. Obesity Algorithm, presented by the Obesity Medicine Association. 2017-2018. Accessed Sept 14 at: www.obesityalgorithm.org. 
2. Bohula EA, Wiviott SD, McGuire DK, et al. Cardiovascular safety of lorcaserin in overweight or obese patients. N Engl J Med. 2018;379:1107-1117.

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